Implications for clinical practice

The experiments of Chapters 5 and 6 demonstrate that interprofessional collaboration not only depends on predefined team objectives or rules of engagement. Behavioral and perceptual effects of these experiments are beyond mere reasoning. They are the results of active interventions influencing emotionally driven social behavior and team functioning.

Therefore, the attitudes towards an extended scope of practice and independent practice as reported in Chapter 1 are also likely to reflect irrational and social psychological processes.

The same applies for the communicated reasons for opposing or supporting an extended scope of practice as reported in the study of Chapter 2. Therefore, there are two simultaneous priorities of equal importance with regard to interprofessional collaboration and task shifting between dentists and dental hygienists: systemic change and operational change. Even when it is known how to meet all of the requirements to enable interprofessional care, we still depend on the influence of the environmental factors that affect our behavior. With regard to operational change, several implications can be mentioned: sharing a team practice or independent practices in close proximity, task shifting to dental hygienists can improve accessibility of oral health care, the incentives in and structure of the national assurance system should be adapted, new competences of dental hygienists should also be facilitated in practice, and the nature of task shifting should depend on its functionality to integrated care.

7.5.1 Sharing a team practice or independent practices in close proximity

Interprofessional group formation or interprofessional commitment are more difficult when dentists and dental hygienists do not physically work together in close proximity. This indicates that a shared team practice or independent practices in very close proximity should be preferred. Proximity is an essential component of entitativity (the perception of being a group). In turn, entitativity is required for social commitment. When this group is a mixed profession group, commitment of individual group members to their mixed profession group can increase over time. When all team members are committed, the mixed profession group cohesion will increase. Competition with other simular groups can increase the chance this will happen. In turn, group cohesion is a predictor of team performance. When the mixed profession group is cultivated by making interprofessional behavior a performance indicator and when they can compare themselves with a simular mixed profession group, the group members are likely to collaborate interprofessionally with the members of their own mixed profession group. Finally, the mixed profession group will develop into an interprofessional team.

Studies regarding independent dental hygiene practice show no increased risk to patient safety (e.g., Astroth & Cross-Poline, 1998; Innes & Evans, 2013; Freed, Perry & Kushman, 1997). When dentists and dental hygienists share the same practice location, small groups will express more and stronger cohesion than large groups or individuals that work independently

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from a distance. In large team practices, it will be wise to introduce several mixed profession groups between which interprofessional intergroup comparison is facilitated. In addition, interprofessional behavior should be rewarded and not just financially. Selfish and egocentric behaviors are potentially stimulated by only focusing on individual rewards and feedback.

When applying the extended professional identity theory in clinical practice, mixed professions groups should be enabled to compare the interprofessional behavior and performance of other mixed groups or practices with their own mixed group or practice.

7.5.2 Task shifting to dental hygienists can improve accessibility of oral health care

Dental hygienists play an essential part in oral health care with regard to prevention (Thevissen, De Bruyn & Koole, 2016) and especially when diagnostic tasks are shared to enable clinical concertation. The dental hygienist could also, in collaboration with the dentist and other oral health care professionals, improve oral health care in additional ways such as performing additional dental tasks. Task shifting can be cost-effective (Beach, Shulman, Johns

& Paas, 2007; Matthiesen, 2012), and dental hygienists who perform basic dental tasks can improve the accessibility of oral health care (Bell & Coplen, 2016; Myers, Gadbury-Amyot, VanNess & Mitchell, 2014).

7.5.3 The incentives in and structure of the national assurance system should be adapted Several barriers limit task shifting to dental hygienists. Financial systems can negatively influence the dissemination of task shifting in oral health care (Brocklehurst et al., 2016;

Coplen & Bell, 2015). This financial infrastructure, of which insurance companies are a part, is not always perceived by patients as being adequate (Edgington & Pimlott, 2000). In addition, to assure that dentists and dental hygienists do not pay too much attention to the needs of relatively healthy individuals, the delivery of dental care should be in accordance with the severity of the disease, and these oral health care providers should share views on diagnosis and treatment (Leisnert et al., 2015). The incentives in and structure of the national insurance system should be adapted to change these patterns.

7.5.4 New competences of dental hygienists should also be facilitated in practice

Besides the economics of oral health care, sustaining the competence of dentists and dental hygienists also remains of major importance. Just like dentists, dental hygienists should be facilitated in maintaining their competence through regular practice. Skills are acquired during undergraduate training and should be maintained after graduation. However, in practice, this opportunity is not always reality (Jerković-Ćosić et al., 2012; Northcott et al., 2013; Virtanen et al., 2011). In addition, task shifting can lead to polarization between professions like dentistry and dental hygiene (Adams, 2004; Knevel et al., 2016; Northcott et al., 2013; Ross & Turner, 2015). This polarization can subsequently lead to the underutilization of the dental hygienist (Knevel et al., 2016; Kreindler, Dowd, Dana Star & Gottschalk, 2012). Polarization between professions reflects social-political processes that also seem normal between other medical

professions, nursing, and allied health occupations (Macdonald, 1995).

Several studies report that patients trust in the competence of dental hygienists and their ability to function independently (e.g., Edgington & Pimlott, 2000; Innes & Evans, 2013;

Phillips, Shaefer, Aksu & Lapidos, 2016; Turner & Ross, 2017). Many studies provide evidence that they are competent when performing specific dental tasks (e.g., Brocklehurst et al., 2012;

Daniel & Kumar, 2016; DeAngelis & Goral, 2000; Macey et al., 2015; Post & Stoltenberg, 2014;

Öhrn et al., 1996). Another study reports that dental hygienists are confident about their own competence and about working without dental supervision (Catlett, 2016). However, many patients are not well-informed about the role and qualifications of these individuals, and this makes it difficult for them to have a realistic opinion about task shifting (Brocklehurst et al., 2016; Pippi, Bagnato & Ottolenghi, 2017).

7.5.5 The nature of task shifting should depend on its functionality to integrated care Inherent to interprofessional collaboration is professional autonomy (e.g., D’Amour et al., 2005; Headrick et al., 1998). Shifting tasks to dental hygienists not only concerns extending their scope of practice with or without certain dental supervision requirements (Johnson, 2009). The types of specific tasks shifted to the dental hygienist can vary per country, and specific dental tasks have distinct functions in oral health care. It is important to understand why certain dental tasks should be shifted to the dental hygienist and to what degree. Task shifting can have at least three different functions: intraprofessional (as an addition to profession-specific care), multiprofessional (coordination of shared case load), and interprofessional (for clinical concertation by shared diagnostic tasks). Local anesthesia for painful periodontal treatments and dental radiography to identify potential bone loss are examples of functional additions to the periodontal treatment by dental hygienists (Nield-Gehrig & Willmann, 2008). Cariologic diagnosis by dental hygienists can have different functions. Dental hygienists can discover caries when cleaning teeth and removing calculus. Dental radiography, initially used for periodontal diagnostic purposes, can sometimes show tooth decay before it becomes visible (Zadik & Bechor, 2008). Therefore, both dentists and dental hygienist can contribute to optimizing caries management with a multifunctional utilization of dental radiography.

When used properly, this might improve oral health care efficiency. An effective sharing of dental radiographs and other diagnostic information between dentists and dental hygienists might also lower costs. Another function of cariologic diagnosis by the dental hygienist is not only to identify caries but also the degree of its complexity. Based on such an assessment, the dental hygienist could consult a dentist or refer to a dentist when the caries is overly complex and restorative procedures are not allowed to be performed by the dental hygienist. This way, the dental hygienist can focus on more common and less complex cariologic problems, share the case load with dentists, and make oral health care more accessible. When dentists and dental hygienists commit to an interprofessional practice in which they combine their added value, a dental hygiene diagnosis should also be conducted by the dentist. In that case, the